Manifesting, also known as the Law of Attraction, has become a popular point of view that suggests that we can attract what we focus on…to turn something we are thinking into a reality. There are a lot of self-help books that have made it into the mainstream promoting this perspective, inspiring a movement to think about and envision positive outcomes (e.g., wealth, health, career goals, etc.) as a means to achieve them. Sounds relatively harmless. What could be so bad about positive thinking?
Nothing. Think all the positive thoughts you want! 

But what about negative thinking? 

While manifesting is meant to be used in positive ways, it has a lot of similarities with similar concepts that can wreak havoc for people with anxiety and Obsessive Compulsive Disorder (OCD) called Thought-Action Fusion and Magical Thinking. Thought-action fusion refers to the belief that our thoughts are very powerful and are linked to our behavior; that thinking is the same as doing or makes the feared outcome more likely (either via direct consequences or morally). This belief is often associated with OCD, a disorder in which a person has uncontrollable, intrusive, and distressing thoughts (obsessions), and feels the urge to repeat certain behaviors (compulsions) as a result. Individuals with OCD may believe that simply having a negative thought means a bad thing may happen,  and therefore they try to cancel it out/neutralize, undo the thought through a compulsion or ritual. 
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It’s important that individuals with OCD understand that EVERYONE has negative thoughts. Our brain has over 4000 thoughts a day! Some are bound to be negative. (or even weird/bizarre/senseless/disturbing/etc.) Just because you think something doesn’t mean there's a direct correlation with what will come to pass. 

So what’s a healthy view of manifesting that doesn’t cross the line into Thought Action Fusion? 

The premise of manifesting is that, if we think positively, we are bound to feel more pleasant emotions and have more confidence in ourselves. But, the relationship between the positive thoughts and the positive outcomes in this case is based on the assumption that our positive “mindset” will impact the way we behave and the way we interact with the world around us. For example, if we engage in a positive mindset and believe in our ability to accomplish our dreams, we may be more likely to seek out opportunities that lead to the outcomes we want (what we do have control over). If I really want to accumulate more wealth, money won’t magically fall into my bank account just by wishing it or thinking it (trust me, I’ve tried). Instead, I have to do an action like apply for different job opportunities, speak to a financial advisor, make investments, or even buy a lottery ticket. The same goes for negative thoughts. Thinking negative thoughts will not directly make negative outcomes happen. There’s stuff that has to happen in the middle, like behaviors and actions towards those outcomes. And in the case of OCD, those individuals don’t want the bad things to happen and won’t behave in ways to make those outcomes come true. And sometimes, the unpleasant events that happen in our lives are just out of our control. 

Unfortunately, manifesting can easily turn into “evidence” for individuals with OCD that Thought Action Fusion and Magical Thinking are real things and that their thoughts are indeed dangerous, powerful, and capable of causing harm to themselves or those they love. 

If you find yourself struggling with this concept at times, remind yourself of the times when you thought something bad was going to happen, and it didn’t. And make certain to remember the distinction 

This blog series will help you understand what to expect in Cognitive Behavioral Treatment (CBT) for a variety of different anxiety disorders, OCD, and PTSD. No matter what you are seeking help for, it can be very scary to start treatment. I assume most of my patients enter their first appointment with me with anxiety. I assume this for several reasons. 1. You are taking a big first step in your life to change something that may feel impossible to change; 2. Most of my patients experience an abundance of anxiety on a daily basis and new experiences make us all feel anxiety.

My hope is that this blog series helps you to have a better sense of what to expect in your treatment if you choose exposure-based CBT interventions. First and foremost, the first appointment will be a lot of data collection. In order to determine how I can be helpful, I must determine what your problem looks like. You can plan on me asking you a ton of questions. My goal is to determine what diagnoses you meet criteria for (to ensure I can treat those diagnoses) and to instill some hope in you that I can help you. Just like we would hope our doctors would evaluate what is broken before treating a broken bone and then tell us how they can be helpful, I want to use a scientific approach in my practice and give you some hope that the science works. Although a one size fits all approach does not work for everyone, I apply all evidence-based techniques or techniques that have been supported by ongoing research. In this series, you will find the general what’s and why’s of treatment with me. Also, if you are struggling with the motivation to get started, I include some information on why it may be worth it to take a chance on this treatment.

Specific Phobia Treatment

​What is a Specific Phobia?

Extreme anxiety about specific situations or objects (American Psychiatric Association, 2013). Phobias range from fears of driving, flying, animals, insects, natural environment (such as storms), and elevators, to needles, vomiting, and medical procedures. They can be incredibly impairing and impact many aspects of your daily life. 

What will we work on? 

• Exposure Therapy: Most of your treatment will involve creating what is called a hierarchy, which is a list of triggers related to you feared object or situation, and then engaging in the activities listed on the hierarchy (Craske et al., 2006). For instance, if you are afraid of spiders, your first exposure exercise, in which you are exposed to the fear, might be to look at image of spiders online or even to picture a spider in your head. Slowly, I will ask you to do more challenging exposure activities. 

• Cognitive Therapy: While you engage in exposure therapy, I will challenge your thoughts about the feared object or situation (Craske et al., 2006). How likely is it to cause serious harm? How likely are your fears in the first place? If the fear does come true, how will you cope with it? These are the questions we will process together. 

• Insight: Gaining insight into both the origins of your phobia and how your phobia impacts your daily life, will be part of your treatment journey (Craske et al., 2006). At the beginning of treatment, I will help you understand what maintains specific phobias. The answer is quite simple: Avoidance. Oftentimes, my patients will encounter something scary to acquire the phobia in the first place. Sometimes this is through experiencing trauma involving your feared situation or object, sometimes through observing or seeing someone else afraid of or hurt by the situation or object, and sometimes through learning information about the dangers of the object or situation (Craske et al., 2006). Understanding the origins of and maintaining factors will assist you in overcoming the fear and maintaining your gains in treatment. 

Why Engage in this Treatment?

I am assuming you are reading this page because you are tired. Tired of structuring your life around your phobia? Tired of feeling unable to engage in certain parts of your life because you are afraid you might encounter your feared object or situation? Maybe your phobia is starting to impact your sleep, your relationships, and generally your ability to enjoy your life, without the persistent fear in the back of your mind (Grayson, 2014)? Maybe you are unable to travel or to drive or to perform day to day tasks without fear? If so, you may want to give treatment a try. 

Why this treatment works? 
At some point, it is likely you were living your life without constant fear related to your phobia. However, over time, your amygdala, the threat detector in your brain, has falsely programmed your response to your feared object or stimuli. Over time, we will create new associations to override the old ones and this treatment helps you see, by facing the fear, that it is not as threatening as it feels now. 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Craske, M. G., Antony, M. M., & Barlow, D. H. (2006). Mastery of Your Anxiety and Panic: 
Therapist Guide (2nd ed.). Oxford University Press.

Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.

Thinking errors, also known as cognitive distortions, are basically thinking patterns that can be problematic in that they are often inaccurate, unhelpful, and can be harmful to someone’s mental health. Individuals with Obsessive Compulsive Disorder tend to engage in specific types of thinking errors that we try to target in treatment. 

Intolerance of Uncertainty

This thinking error is thought to be a hallmark of OCD.

Individuals with OCD often feel that they MUST have 100% certainty, that they must eradicate all doubt, and that 100% certainty is possible as long as they figure out a way to achieve that certainty (e.g., checking over and over again, obtaining reassurance from others, body scanning, etc.). Any possible doubt that their fear could be true is considered intolerable and unacceptable. 

Significance of Thoughts

Individuals with OCD give their thoughts a lot of meaning and importance. In fact, this is one of the main ways which OCD “hooks” them into a trap. For example, an individual with OCD may have an intrusive image of pushing someone into the street. While this thought could very well also happen to someone without OCD (in fact, we know that the kinds of thoughts that individuals with OCD have do not differ from individuals without OCD), an individual with OCD might interpret this thought to mean something about themselves, such as that having the thought means they are more likely to actually push someone and harm them (also known as Likelihood Thought-Action Fusion), or that they are a “bad” person for having the thought (also known as Moral Thought-Action Fusion). Whereas an individual without OCD might interpret the meaning of the thought to be senseless, meaningless, and not reflective of themselves or their intentions…that the thought was just a mental “blip” (and they are also comfortable with not having to “prove” or be 100% certain of this). 

The “Significance of Thoughts” thinking error is often seen in individuals with “Harm Obsessions” (e.g., accidentally harming someone, losing control, acting on an impulse) and/or “Unacceptable Thought Obsessions” (e.g., obsessions related to sex or violence - seen as unacceptable by the person with OCD). 

Another related thinking error is the belief that it is very important and possible to control thoughts (Need to Control Thoughts).

The Big 3

The Big 3 Thinking Errors tend to be common across all anxiety disorders and OCD:

Overestimation of Cost: Individuals with OCD tend to overestimate the severity of their feared outcomes
Overestimation of Likelihood: Individuals with OCD tend to overestimate the likelihood of bad things happening
Underestimation of Self-Efficacy: Individuals with OCD tend to under-estimate their ability to handle feared outcomes 

Overestimation of Responsibility

Individuals with OCD tend to take on a LOT of responsibility for their thoughts and behaviors. They believe that they must prevent bad things from happening to themselves or others (usually specific to the content of their obsessions), that they have the power to do so, and/or that they won’t be able to tolerate knowing they could have prevented something bad happening if something bad did happen. 

Perfectionism  and the “Just Right” Error

Individuals with OCD may feel that things must be perfect, “just right,” or symmetrical/evened-out in order to feel less distressed and/or in order to prevent bad things from happening (e.g., Magical Thinking). Often times, intolerance of anxiety or the fear that anxiety will be perpetual are related to this kind of thinking error (e.g., “If I don’t make this even, I will feel anxious forever”). 

Exposure and Response Prevention (ERP) is a treatment approach that attempts to alter these thinking patterns/errors via beahvioral learning principles and the development of safety associations. To learn more about ERP you can use these links:

Exposure and Response Prevention  - OakHeart, Center for Counseling
Exposure and Response Prevention - International OCD Foundation
​What to Expect in CBT Treatment Series: OCD - Dr. Hillary Gorin, OakHeart, Center for Counseling

This blog series will help you understand what to expect in Cognitive Behavioral Treatment (CBT) for a variety of different anxiety disorders, OCD, and PTSD. No matter what you are seeking help for, it can be very scary to start treatment. I assume most of my patients enter their first appointment with me with anxiety. I assume this for several reasons. 1. You are taking a big first step in your life to change something that may feel impossible to change; 2. Most of my patients experience an abundance of anxiety on a daily basis and new experiences make us all feel anxiety.

My hope is that this blog series helps you to have a better sense of what to expect in your treatment if you choose exposure-based CBT interventions. First and foremost, the first appointment will be a lot of data collection. In order to determine how I can be helpful, I must determine what your problem looks like. You can plan on me asking you a ton of questions. My goal is to determine what diagnoses you meet criteria for (to ensure I can treat those diagnoses) and to instill some hope in you that I can help you. Just like we would hope our doctors would evaluate what is broken before treating a broken bone and then tell us how they can be helpful, I want to use a scientific approach in my practice and give you some hope that the science works. Although a one size fits all approach does not work for everyone, I apply all evidence-based techniques or techniques that have been supported by ongoing research. In this series, you will find the general what’s and why’s of treatment with me. Also, if you are struggling with the motivation to get started, I include some information on why it may be worth it to take a chance on this treatment.

Health Anxiety Treatment

What is Health Anxiety? 

Health anxiety (or Illness Anxiety Disorder) is anxiety about your health (simply put). It involves a fear of getting or having a serious illness. This anxiety often drives patients to either repeatedly check their bodies for health or illness or avoiding evaluating their health, as seen by avoiding doctor appointments all together (Abramowitz & Braddock, 2011). Recently, I have seen specific COVID-19 related anxiety which similarly presents as anxiety about acquiring, having, or contracting COVID-19. 

What will we work on? 

• Exposure therapy: Instead of running away from medical fears, I will encourage you to “sit with” them (Abramowitz & Braddock, 2011) . What does this mean? If you are afraid of going to the doctor, you will think about going to the doctor. If you are afraid of cancer, you will think about cancer. If you are afraid of medical procedures, you will watch videos on medical procedures. If you are afraid of having a heart attack, you will read about having a heart attack. I will assist you with repeating such exercises until the fears start to subside. In addition, I will teach you strategies on how to approach, rather than avoid, such fears. Avoidance fuels anxiety. 

• Cognitive Strategies: I will ask you to become a scientist (Abramowitz & Braddock, 2011). What evidence do you have for and against the medical fear coming true? If the fear does come true, would you survive it? How so? These are questions we will process in treatment. 

• For some patients with medical anxiety, they are very aware of every sensation or abnormality in their body (Abramowitz & Braddock, 2011). For instance, they may pay close attention to their heartrate and breathing patterns to ensure they are not having a medical emergency. I may ask my patients to engage in exercises that mimic these sensations so that they can learn to tolerate them when they occur, without believing they are a sign of a serious medical illness. For example, I may ask you to engage in physical exercise while thinking about a medical illness to realize that thinking of illness does not equate to having it. 

Why Engage in this Treatment? 

Consider the ways your life has been negatively impacted by your health anxiety (Grayson, 2014). Can you prevent medical problems by thinking about them or researching them? Does your medical anxiety impact your ability to care for yourself, to go to your appointments, to manage the COVID-19 pandemic?  Does it impact your ability to enjoy your life? If so, you may want to give treatment a try. 

Why this treatment works? 

We can’t predict the occurrence of medical problems, for the most part. However, what I can predict is your ability to learn to tolerate this reality. We all will face medical problems at some point. By facing this fear, we can stop thinking about this reality and start living in our present reality again. 

References

Abramowitz, J. S. & Braddock, A. E. (2011). Hypochondriasis and Health Anxiety: Advances in Psychotherapy Evidence-Based Practice. Hogrefe.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.